A Woman's Journey With Rare Disease

Love/Hate With Health Insurance

Many people don’t realize this but many common issues regarding premiums & claims were present before healthcare reform. I even experienced them myself for a few years when I made the mistake of selecting a plan that looked good on paper, but in reality was quite the opposite. (I even found an error but was never given a way to be able to submit proof to have it corrected). This was back quite awhile ago, & also part of what prompted me to take a position in customer service in health insurance when I found an opening a few years ago. I learned so much. Some knowledge I’m glad I have & other knowledge I wish I didn’t…

It’s a rough gig, but like most call centers, agents are timed on their calls, especially with the major carriers. If they go over the allotted time per call, they might get it counted against their averages regardless of whether or not they are actually serving the customer with that extra time.

Luckily, my employer (which was a small administrator) actually encouraged me to assist people & remain on the phone as long as I needed to as long as I was being professional & helpful. I wasn’t timed.

I took an average of at least 60 calls a day for the little over 2 years I was in that position before I was promoted. Then I still helped, but primarily brokers & employers with claims issues amongst other things.

So I do get people’s frustration from both ends because most of these calls aren’t focused on service like they should be.

What most people don’t understand is the majority of health insurance claims are processed through computers, screened through the billing codes first.

If one of those codes is incorrect or worse yet, not an “eligible” code according to the plan, the claim will automatically deny. The automation is to make sure examiners don’t get overwhelmed & can focus on more complex claims that do need review. It is also an attempt to process most routine claims (like those for standard doctor visits) in a faster time frame.

So when I see “hack” memes like this, I have to shake my head. Please don’t waste time on these. (Instead waste time on the memes like the feature image attached to this post on my homepage about bypassing automated menus. Memes like those actually have a shot in hell of working, at least more so than the below one does.)

The best thing to do is have the agent send back the claim for reprocessing to make sure it was processed correctly & also ask for a detailed explanation of why the claim denied.

Most are due to incorrect coding either in the diagnosis or procedure code used to bill it. I don’t have coding experience myself, but I spent many a time on the phone looking up that detail to find out exactly what was being billed & verifying the person actually did receive those services.

Also, every plan has exclusions or limitations on coverage. By law, when asked, the insurance company has to provide you with a list of exclusions as well as the language of what is eligible. Ask them for the full section of the policy for “eligible expenses” & exclusions. It’s good to know ahead of time, but sometimes there are things & diagnoses that are not covered & there might be a specific exclusion for that.

For example, many plans no longer cover sleep studies for sleep disorders unless it’s medically necessary treatment. Therefore, if some office bills for a sleep study but fails to submit information from your medical record as to why they ordered it, the claim will automatically deny because there was no information submitted with the claim to prove that the treatment was actually necessary.

In those cases, finding that out & having the doctor submit that missing information may be enough to have it reconsidered & reprocessed.

As always you have the right to appeal or request more information on any claim denial that you don’t understand. You may not agree with the determination but you have the right to contest. The appeal may not succeed, but the insurance company is obligated to explain their rationale when asked.

The above meme just wastes time with the wrong people. There’s usually a formal appeals process outlined in each plan that has to be followed.

Now, having experience on both sides of the coin, I’ll show you what my big pet peeves are….

Articles like this one & this other one, too. Why? Because both are true. But what most people don’t understand is that these were very problematic even before the days of healthcare reform as well.

Also the money that is going into these executives pockets isn’t being redistributed down the chain to the people doing the majority of the work, either. Especially in the customer care sector, that’s not who is getting the majority of any “trickle-down bonuses”, even though they are often on the front lines & the face of these companies. The wealth isn’t being shared, except in a few small examples & usually confined to third parties, not major carriers or networks.

All of these pet peeve issues now are just more prevalent because more people are experiencing the ramifications of them first hand with their employer’s group insurance or private policy.

I’ll tell you who dictates the majority of these decisions on premiums & coverage. It’s the underwriting process. If we want to talk reform, we have to start there. That is the department that holds the cards.

If an employer group has too high of a proportion of sick people, since they can’t exclude coverage anymore, they instead increase the premium, & possibly also offer alternatives in the form of plan changes, offerings, or adjustments (revisions) for lowering coverage or foisting more cost sharing to the person (employee) directly, like increasing the deductible to appease employers or explain away premium increases.

Same holds true with drug costs, making someone meet a deductible before their co-pays kick in or raising the deductible and making sure that prescriptions are built into that deductible along with medical expenses. Or even just setting up co-pays or cost sharing just on specialty drugs.

It’s common practice to do this in major insurance companies & pitch it as a cost-saving measure to force employers to pay more for less benefits to cover their employees. Then also to make sure the employees have to pay something for the coverage in addition to just the premium payments alone.

That also spills over into to the marketplace offerings, especially in states without an exchange, there’s no incentive to offer a good basic plan. Especially for those who fall in the coverage gap. They don’t make enough to claim a subsidy or tax credit but also don’t qualify for Medicaid. Those people are stuck paying the penalty or paying more for a subpar plan.

The second article I find irksome because this is also true. It’s backdoor dealings like these that cause most pricing transparency issues. The facility or hospital system or insurer effectively strong arm the other party into a negotiation deal. I’ve seen it work both ways as to who has the most leverage, but this in turn also affects what people pay whether they pay cash or whether they are insured & pay through the plan. Discounts don’t have parity between insurance carriers or offices.

They vary as do the costs for services. It’s not like getting an estimate for a car repair or home repair and filing the claim through those insurances. It should work that way & would be way easier to understand if it happened that same way but it doesn’t.

I try to get people to care about these peeves too regardless but most don’t until they are faced with a situation that forces them to or opens their eyes to it & makes it real. Yet, I hate to say it’s going to get worse before it gets better.

I’ll be interested to see what happens with my plan next year. It’s changing. My deductible didn’t double but it went up, as did my out-of-pocket, but for most services the coverage looks a bit better.

The specialty drugs I know I will pay through the nose for but I was expecting that too. It’s a given now, just like deductible increases.

I don’t know since I’m not changing insurance networks (just who oversees it) if the pricing on my transplant will be the same or different. I’m really glad I set up my medical fund when I did to offset the potential increased drug costs after my transplant because I’m most likely going to feel most of the pain there.

My monthly premium actually went down from what it was, which was a pleasant surprise.

I only hope that most of my drugs will be covered without unnecessary nonsense like needing authorizations or appeal letters beforehand, but I guess I’ll find out.

I did take a look at the marketplace & I couldn’t have done much better. Though I at least had a few resources I became aware of recently to help me & other people I know shop competitively. That always helps & is good information to have in the back of one’s pocket for future reference, just in case.